Rehabilitation in osteoporotic vertebral fractures

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(1)Mini-review. Elisa Pratelli1 Irene Cinotti2 Pietro Pasquetti1 Recovery and Rehabilitation Agency, University Hospital of Careggi, Florence, Italy 2 Postgraduate Specialization School in Physical Medicine and rehabilitation, Faculty of Medicine, University of Florence, Italy. extra-vertebral fractures (6). Once the first vertebral fracture has occurred there is a higher risk equal to 20% of further vertebral fractures in the first year (“vertebral fracture cascade”) (7). In the development of the “vertebral fracture cascade” phenomenon, besides the bone mineral density, other factors such as bone intrinsic properties, local and global spine properties, neurophysiologic properties are indicative of the risk. The above mentioned factors contribute to increase the risk of new vertebral fractures in patients with a comparable T-score value (8-10). The presence of previous vertebral fractures also makes the prognosis worse in terms of disability, autonomy in the ADL, and life quality (11). A well-timed diagnosis and treatment is necessary in preventing further vertebral fracture consequences. The most frequent levels of vertebral fractures are located between D6-D8 and the dorso-lumbar passage D12-L1. In order to diagnose vertebral fractures the instrumental exam for reference is the spinal x-ray in two projections. Through the morphometry, the type and the gravity of the fractures can be established (12). In order to evaluate completely a vertebral fracture case the Spinal Deformity Index (SDI) can be utilised (13, 14). The SDI is a summary measure for a total semi-quantitative evaluation of vertebral deformities on the spine. For each vertebra, a visual semiquantitative grade of 1, 2 or 3 is assigned if there is a decrease in vertebral height: mild (1-height decrease 20%-25%), moderate (2-height decrease 26%.40%) or severe (3more than 41%) fracture; the SDI is calculated by summing the fracture grades of all vertebrae. The initial severity of the vertebral deformity is a negative prognostic index for persistent pain and disability (15). The treatment of vertebral fractures related to fragility can be conservative or surgical and aims to heal the fracture, pain control and the prevention of further deformities. While pharmacological treatment shows strong scientific evidences, the conservative treatment in vertebral fractures including rehabilitation is nowadays not well-documented. Conservative treatment comprises management of acute vertebral fracture, the post-acute phase, the rehabilitation phase, the treatment of a possible background disease and the education of the patient aiming for the prevention of further fractures. In the acute and post-acute stage the most important factors of the treatment are pain control with pharmacological treatment and physical treatment, the prevention of complications, the use of orthopaedic corsets, frequent check-up concerning the spine and specific physiotherapic training. The acute phase when the patient is bed-ridden, should be as short as possible. Scientific literature recommends having the patient stay in bed as brief as possible (16-19) in order to avoid the complications (National Osteoporosis Foundation). A protracted bed stay would cause muscle hypotrophy and weakness and joint rigidity even at extra-vertebral level; moreover it can lead to development of bed sores, deep-vein thrombosis, respiratory diseases, disorientation and depression. During the stage in-bed it is advisable to begin educating the patient on the correct positions to maintain in bed and in posture passages. Moreover, patients can begin doing neuromuscular stabilization exercises of the toraco-lumbar spine that don’t require any mobilization. Patients can also begin passive and active exercis-. rn a. 1. zi on al i. Rehabilitation in osteoporotic vertebral fractures. In. te. Address for correspondence: Elisa Pratelli, MD Recovery and Rehabilitation Agency University Hospital of Careggi Largo Palagi 1, 50134, Folrence, Italy Tel: +39 339 4821770 Fax: +39 055 7948476 E-mail: pratelli.elisa@libero.it. Summary. iz. io. ni. Vertebral fractures occur particularly in osteoporotic patients due to an increased bone fragility. Vertebral fractures influence the quality of life, mobility and mortality. Preventive training exercises and proprioception reeducation can be utilised for improving posture, balance and level of daily function and for decreasing pain. Quality of life is improved even beyond the active training period. This mini review provides information based on the literature for the rehabilitation of osteoporotic vertebral fractures after conservative or surgical treatment.. Ed. KEY WORDS: vertebral fractures, osteoporosis, rehabilitation.. ©. C. IC. Osteoporosis is defined as an increase of bone fragility due to alterations in bone quality and quantity factors. As stated by OMS, osteoporosis is shown with a bone mass decrease of more than 2.5 SD compared with the mean value obtained by the youth population reference, T-score <= 2.5 SD. The EVOS study (European Vertebral Osteoporosis Study) and the EPOS study (European Prospective Osteoporosis Study) (1), as indicated by European levels, show a prevalence in osteoporotic vertebral fractures of 12.2% in men as well as in women; and an incidence of 10.7 % in women and of 5.7% in men on patients over 50 years old. As indicated by these analysis it can be expected that in patients over 50 years old there will be circa 1.4 million vertebral fractures per year in Europe. Moreover, since only 40%-60% of vertebral fractures are diagnosed (2-4), a remarkable percentage of events will go unnoticed. Osteoporotic vertebral fracture consequences are various: organic, psychological, social and public health issues, either short or long term (5). The presence of vertebral fractures is associated with a decrease in the quality of life and with an higher risk of further vertebral and Clinical Cases in Mineral and Bone Metabolism 2010; 7(1): 45-47. 45.

(2) E. Pratelli et al.. References. te. rn a. zi on al i. 1. EPOS Group. Incidence of vertebral fracture in Europe: results from the European prospective osteoporosis study (EPOS). J Bone Miner Res 2002; 17(4): 716-24. Ismail AA et al. EVOS-Osteoporosis Int 1999, 9: 206.. 2. Patel U. et al. Clinical profile of acute vertebral compression fractures in osteoporosis. Br J Rheumatol 1991; 30 (6): 418-21. 3. Ross PD. Clinical consequences of vertebral fractures. Am J Med 1997; 103 (2A): 30S-42S. 4. Cooper C. et al. Incidence of clinally diagnosed vertebral fractures: a population- based study in Rochester, Minnesota, 1985-1989. J Bone Miner Res 1992; 7(2):221-7. 5. Suzuki N. et al. The course of the acute vertebral body fragility fracture: its effect on pain, disability and quality of life during 12 months. Eur Sine J 2008, 17: 1380-1390. 6. Salaffi F. et al. The impact of vertebral fractures on quality of life in postmenopausal women with osteoporosis. Validity of the Italian version of mini-Osteoporosis Quality of Life Questionnaire. Reumatismo 2005 Apr-Jun;57(2):83-96. 7. Lindsay R. et al. Risk of new vertebral fracture in the year following a fracture. JAMA 2001, 285:320-323. 8. Briggs AM et al. The vertebral fracture cascade in osteoporosis: a review of aetiopathogenesis. Osteporos Int 2007, 18:575-584. 9. Tzermiadianos M.N. Et al. Altered disc pressure profile after an osteoporotic vertebral fracture is a risk factor for adjacent vertebral body fracture. Eur Spine J 2008, 17:1522-1530. 10. Ruyssen-Witrand A. et al. Vertebral dimensions as risk factor of vertebral fracture in osteoporotic patients: a systematic literature review. Osteoporos Int 2007, 18: 19271-1278. 11. Suzuki N. et al. Previous vertebral compression fractures add to the deterioration of the disability and quality of life after an acute compression fracture. Eur Spine J, September 2009. 12. Black DM et al. Defining incident vertebral deformity: a prospective comparison of several approaches. The Study of Osteoporotic Fractures Research Group. J Bone Miner Res 1999b;, 14(1):90-101. 13. Minne HW et al. A newly developped spine deformity index (SDI) to quantitate vertebral crush fractures in patients with osteoporosis. Bone Miner 1988,3(4):335-49. 14. Genant HK et al. Vertebral fracture assessment using a semiquantitative technique. J Bone Miner Res 1993,8(9):1137-48. 15. Suzuki N. et al. The prognosi for pain, disability, activities of daily living and quality of life after an acute osteoporotic vertebral body fracture: its relation to fracture level, tipe of fracture and grade of fracture deformation. Eur Sopine J 2009, 18: 77-88. 16. Bonner FJ Jr et al. Health professional’s guide to rehabilitation of the patient with osteoporosis. Osteporos Int 2003, 14(Suppl 2): S1-22 17. Rapado A. General management of vertebral fractures. Bone 1996, 18 (Suppl 3): 191S-196S. 18. Heggeness MH et al. An orthopaedic perspective of osteoporosis. Osteoporosis 2nd ed. vol. 2. New York: Academic Press 2001, 485-99 19. Dionyssiotis Y. et al. Rehabilitation after falls and fractures. Musculoskelet Neuronal Interact 2008, 8(3):244-250. 20. Frost HM. Personal experience in managing acute compression fractures, their after math and the bone pain syndrome, in osteoporosis. Osteoporos Int 1998, 8:13-15. 21. Itoi E et al. Effect of back-strengthening exercise on posture in healty women 49 to 65 years of age. Mayo Clin Proc 1994, 69(11): 1054-9. 22. Sinaki M. et al. Balance disorder and increased risk of falls in osteoporosis and kyphosis: significance of kyphotic posture and muscle-strength. Osteoporos Int 2005, 16:1004-1010. 23. Sinaki M. et al. Reducing the risk of falls through proprioceptive dynamic posture training in osteoporotic women with kyphotic posturing: a randomized pilot study. Am J Phys Med Rehabil 2002, 81 (4): 241-6. 24. Sinaki M. et al. Stronger back muscles reduce the incidence of vertebral fractures: a prospective 10 year follow-up of potmenopausal women. Bone 2002, 30(6): 836-41. 25. Sinaki M. Critical appraisal of physical rehabilitation measures after osteoporotic vertebral fracture. Osteoporos Int 2003, 14:773-779.. ©. C. IC. Ed. iz. io. ni. In. es with mobilization of upper and lower limbs and of the cervical spine to avoid rigidity and to reduce the muscular hypotrophy. The placement of an orthesis with specific characteristics which depends on the level and severity of the vertebral fracture is necessary to enable the patient to stand up. Corsets used in clinical practice are the thoracic-lumbar-sacral orthosis (TLSO), the rigid corset with a tree-point pressure system, and for special events is used a less restrictive corset to provides support to the lumbar region (20). The vertebral orthesis treatment has to last 8-12 weeks approximately to encourage the fracture’s complete stabilization. During the two months after the acute vertebral fracture physiotherapic exercises should avoid the intensive muscular strenghthening (16) focusing on relaxing exercises, maintaining joint mobility of the major joints, and breathing exercises. The most intensive rehabilitation phase can start during the corset wearing and has to proceed after the orthopaedic corset is removed, generally in 8-12 weeks from the acute event depending on a radiographic control and the pain symptomatics. The rehabilitation program basicly includes back-extensor muscle strenghthening exercises, postural retrainig exercises, ergonomic and balance increasing exercises. The back-extensor muscle strenghthening decrease the kyphotic posture (21) which predisposes to back pain and to a higher risk of falls and secondary fractures (22). Proprioceptive postural retraining improve balance (23-25) decreasing falls risk. Vertebral stabilization exercises, balance training, stretching and relaxing techniques are operative reducing chronic pain and disability of vertebral fractures patients (26-28). The way exercises are performed, the frequency, the length of time and the setting of sessions have to be adapted to the clinical state based on an individual rehabilitative project. Generally sessions are scheduled two or tree times a week, lasting 45-50 minutes to patient’s house or in suitable structures. Moreover, there are evidences that muscle strenghthening exercise helps to maintain appropriate measurements (in bone mineral density, obtained from DXA) in postmenopausal woman (29). In the re-conditioning phase that starts with removal of vertebral orthesis, in addition to physiotherapic exercises is basic the recovering of the psychic-gesture abilities, and the restarting of normal activities of sport and work; all for a complete patient’ social reinsertion. The surgical treatment of vertebral fragility fractures is based on vertebroplasty and kyphoplasty, which are both mini-invasive interventions. The surgery treatment indications are basically a lean pain control by conservative treatment, the vertebral deformity progression and the choice of a fully informed patient. Both techniques are very useful in pain control, with an improvement in the 60%100% of cases (30, 31). Kyphoplasty seems to give better results on disability reduction, and about the quality of life (31). Complications of both methods are basically due to the medical treatment and to the happening of new vertebral fractures. Vertebroplasty seems to have a statistically significant increased rate of procedure-related complications and cement extravasation (32). Even after vertebroplasty or kyphoplasty, physiotherapic back-extensor muscle strenghthening exercises with a proprioceptive postural retraining decrease radically the incidence of a further vertebral fracture increasing the time between the two events (33). In conclusion we can say that physical rehabilitative measures play a key role after vertebral fractures and beyond for preventing further fracture, but there is a dearth of controlled trials in this area, perhaps of the lack of founding for non-pharmacologic research. In particular there is a lack of an encoded training program after vertebral fracture. Muscle reeducation, resistance exercises for strenghthening, and reduction of kyphosis are fundamental elements for reducing the risk of falls and further fractures, to improve quality of life and decrease the pain. Further studies about physical rehabilitative measures will help support the convinction that non-pharmacologic rehabilitative management of osteoporosis, when properly used, is beneficial and cost-effective.. 46. Clinical Cases in Mineral and Bone Metabolism 2010; 7(1): 45-47.

(3) Rehabilitation in osteoporotic vertebral fractures. zi on al i. 30. Hulme PA et al. Vertebroplasty and kyphoplasty: a systematic review of 69 clinical studies. Spine 2006, 31(17):1983-2001. 31. Taylor RS et al. Ballon kyphoplasty and vertebroplasty for vertebral compression fractures: a comparative systematic review of efficacy and safety. Spine 2006, 31(23):2747-2755. 32. Lee MJ et al. Percutaneous treatment of vertebral compression fractures: a meta-analysis of complications. Spine 2009, 34(11):12281232. 33. Huntoon EA et al. Significantly fewer refractures after vertebroplasty in patients who engage in back-extensor strengthening exercises. Mayo clin proc 2008, 83(1):54-57.. ©. C. IC. Ed. iz. io. ni. In. te. rn a. 26. Malmros B et al. Positive effect of physiotherapy on chronic pain and performance in osteoporosis. Osteoporos Int 1998, 8:215-221. 27. Papaioannou et al. Efficacy of home-based exercise for improving quality of life among elderly women with syntomatic osteoporosis-related vertebral fractures. Osteoporosis Int 2003, 14(8):677-82. 28. Gold DT et al. Group treatment improves trunk strength and psycological status in older women with vertebral fractures: results of a randomized clinical trial. J Am Geriatr Soc 2004, 52(9):1471-8. 29. Nelson ME et al. Effects of high-intensity strength training on multiple risk factors for osteoporotic fractures. A randomized controlled trial. JAMA 1994, dec 28;272(24):1909-14.. Clinical Cases in Mineral and Bone Metabolism 2010; 7(1): 45-47. 47.

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